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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTONCA95202-(209)488-3420 <br /> NON-REFUNDABLE'''P///ffTE(RRMIT CALL 209 953-7697 FOR INSPEC11ONS EXPIRES I YEAR FROM DATE ISSUED f3[1 <br /> JOB ADDRESS �,�6 CITY/ZIP I—SCo./�// gS320 �'^ <br /> CROSS STREET �/a'�a- IO�j' /A/P/N l��O 9 OV'1 PARCELSOM LAND USE APPUCATIO(7�N�0 <br /> OWNER NAME Al T,G rl1 86,1,6 i P.LA i J l "-D ^ IZC�I Ei <br /> OWNER ADDRESS ��TT sawle CITYISTATEIZJP <br /> CONTRACTOR (/`C�I l//� Q P.--36-. i) <br /> CONTRACTOR ADDRESS �- C.ISTATEMP Q j <br /> SUBCONTRACTOR PHONE ` <br /> SUBCONTRACTOR ADDRESS ICrry/STTAATE/ZjP N) <br /> LICENSE -57 C-61 D-09 Other NUMBER -11 2 ',-•-2 ExPIRAT1oN DATE <br /> GEOGRAPHICAL INFOR ATION: Coordinates X Y Township_ Range Section_ ,jam <br /> INTENDED USE Z Domestic/Private Imgation/Agricullural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System t <br /> If different from Owner. Wider SyStem Name Uontact Name or one u r <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Weil( _ 0 of wells Soil Boring(s) 8.1 bnd� Geotechnical a of tonnes <br /> Out- <br /> Cross-Conne <br /> rWELL CONSTRUCTION uew1u a WPum\I Replacement Pump Repair <br /> Well Renewal Raise Well Cas <br /> ing <br /> n Repair i <br /> (Drilling Method Mud Fj�tary Air Rotary Auger Cade Tool C Push Pant Other <br /> Proposed Well Depth R Excavation in dimuter Open Bottom Gravel Pack/Gravel Size In diameter <br /> t—. <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thidmess/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack m-7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> concrete Pedestal Dimensions:Width ft Length R Thick in Christy Box Stove Pipe <br /> PUMP a Su merslble Turbine Other HP J-.�— Pump Set It Standing Water Level h h <br /> I HEREBY ER THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN �J <br /> JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS G <br /> CURRENT AND ACTIVE WITH THE CAUFORNfA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL i <br /> WORKERS COMPENSATION LA IS. <br /> PAJ4 R ADVANCE NOTICE RE/OTT)U,L'(j71EhD�FOR INSPECTIONS n <br /> SIGNED TITLE \.1 VV 1 1�� DATE `{ <br /> PAYMENT <br /> RECEIVED <br /> AN 2 0 2012 <br /> JOAQUIN COUNTY <br /> ENTTH DEPARTTMENT <br /> DEPARTMENT YSE ONLY <br /> Application Accepted By Date L Area Employee IDS�S <br /> Grout Inspection By to711 i <br /> PEC(AL Well Permit <br /> Pump Inspection By Date P2, WAIVER Received <br /> SpA Boring Ins n B Date Constructed Well Depth h <br /> COMMENTS ✓ -- <br /> PE SC Recetved C Amount ate PermiU Invoice 0 Well IDs <br /> Codes Info B ash Remitted Servii uestS <br /> Ai 6,50 ( S-'t Lj <br /> EK)43= WELL/PUMP PERMIT <br /> 8/0a/0f/ <br />